We are picking up where we left off in our interview with Colleen Marshall, Chief Clinical Officer for Vital Decisions, discussing how we can make advance care planning conversations more efficient and how to overcome some common barriers that arise.

Nurses and Physicians are extremely busy and conversations about advance care planning with patients can be difficult and time consuming. What is the key to making these conversations efficient and mutually beneficial?

Colleen: The first step is to understand what can be accomplished in a short period of time and what can’t. In 5 or 10 minutes we cannot have a complete conversation about someone’s unique story, their goals and put together an advance care plan. Thinking about what is necessary for someone to be ready to change (importance, confidence and readiness) we can focus the 5 minutes on understanding one part of this with the hope of follow up on the next parts. So if you only have 5 minutes, use it wisely and use it to truly listen and understand what someone wants for themselves and why they want it. This will build to future conversations when you can help them explore more what is important to them, their ideas and confidence to achieve that and ultimately their readiness to do it.

When I am training nurses and physicians we role play questions for the 5 minute encounter. This might include questions like

What are your goals and what do you hope to accomplish? Why is that important to you? How are you doing vs those goals? What are you hoping to do more of?

This creates an environment where you can provide follow-up material like My Living Voice and pick up the discussion later. If patients are well engaged they will think about these issues between meetings. Not all of the work has to be done face to face in one conversation. Often progress with patients happens in between discussions when they are thinking about what we talked about.

It is also important to recognize that not everyone will engage. If we respect their story and their goals then we have to accept the fact that some people will not engage. We get a 40% engagement rate on the topic of Advance Care Planning. I think that can be higher but I don’t think it can be 100% it might not even be 80%. My best guess is that it can probably be about 60%. That can be a freeing realization and allows you to deal with everyone as an individual not as part of your goal.

You have probably listened to thousands of discussions between patients and counselors about advance care planning. There is often a disconnect between the care people want and the care they are getting. Is there a common theme to what prevents this?

Colleen: There are two common reasons. First, people don’t have all of the information about their situation. You can’t make good decisions if you don’t have enough information. Sometimes this happens because the patient doesn’t ask or doesn’t comprehend what they are hearing. The paradox is that you can’t tell or lecture these patients. That often has the effect of scaring someone which drives their avoidance behaviors even further. Instead we need to listen, ask questions and understand specifically what information they don’t have or understand and what information they want to help them make a decision. Then SHARE that information with them in a space of acceptance and willingness to help them process and clarify and understand. Again, telling vs sharing information may not seem like a big distinction but the difference is in the intention and it makes all the difference.

The second issue is competing priorities. This can cover a whole host of issues from treatment choices to life choices to family dynamics but there is often an element of competing priorities that needs to be worked through. We find that when people try to work through these on their own they either avoid the issues or don’t make choices, they decide not to decide and end up getting the default option or default treatment which is not necessarily what they would have wanted. It really helps to have a coach or someone to talk with to help you think out loud about what is important to you, and if you have to, how would you make these hard choices.

A large percentage of patients you deal with tell you that they are ‘all set’ and their family knows what they want. What do you do with that sort of response?

Colleen: Like everything else the first thing is to understand and be curious about this answer. Maybe that is true but often that is not the case. I would often affirm this response and then explore it at its extremes. So if a patient tells me that she has talked to her family and they know what she wants the first thing I want to do is let her know that that is amazing and not everyone has done that and it is great that she has taken that step. I would also want to know why she took that step, why was that important for her to do.

When I explore the extremes of this answer I do not want to be judgmental or challenging in any way but curious, I may ask something like:

So you are confident that your family knows everything you would want if faced to make a decision for you? For instance, a lot of people say they don’t want to be on a ventilator but what they really mean is that they don’t want to be on one for a long time but if it was just 24 hours or so they would want one. Your family understands how you feel about that issue if there where different time frames our different possible outcomes?

The key to the question is my intention, to clarify, not challenge. If she hasn’t thought about the issue at that level of detail then I can help her think that through and there are probably a lot of other details that we can work on together as well.

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Thank you to Colleen for sharing her thoughts. If you would like to talk to her more about this you can contact her at CMarshall@vitaldecisions.net